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PROOF OF INSURANCE (2018 - 2018) CLOSED Client#:48149 GYMME ACORDTM CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDDIYYYY) 9/28/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES i BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT .. IN,AME Tegner-Miller Insurance P HONE I 662 TAX (AIRNNE.. License#0K07568 E-MAIL Ext 310 828-9 IA/ Nip 310-453-7971 1. 2001 Wilshire Blvd.,#101 P INSURER(S)AFFORDING CpOVE�GE NAICR Santa Monica, CA 90403 INSURER A: Star Insurance Company INSURED INSURER B: J.Marvin Campbell .... .. .. . dba: The Gym Mechanic INSU!11RER c NS I4248 Vinton Ave INsuRER..E...................................... Culver City,CA 90232 INSURER F................... COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTP Y EX TYPE OF INSURANCE NSR IW.VP POLICY NUMBER (MMIDOY ) (P�JR' AbbCsUbk EFFPI U9 MMYY,) LIMITS„ A GENERAL LIABILITY X CPV001629509/15/2017 09/15/2018 EACH OCCURRENCE $1,000,000 COMMERCIAL GENERAL LIABILITY N4AM•f'h��pflFM'�'(f" R&"�kThD W I} MVI �-1 1E,R d7rv„9:4,Tr44j ..1 OOa000 , CLAIMS-MADE OCCUR MED EXP(Any one person) $5,000 XBIIPD Ded:500 PERSONAL&ADV INJURY $1,000,000.................................... GENERAL AGGREGATE $2,000,000 GE i LAGGREGATE LI M MITT APPLIES PER: PRODUCTS-COMP/OP AGG $2,,000,000 iE LOC _ $ AUTOMOBILE LIABILITY COMOINFUT SthOl'.aLF U,.U�dUT(Fa?caa9 ptp. .,.. ANY AUTO �,,BODILY INJURY(Per person) $ ALL OWNED ^ SCHEDULED Per accident AUTOS AUTOS BODILY INJURY( ) $ ...�_... HIRED AUTOS .. NON-OWNED f • pee 'Y bAvA,G. $ ....... AUTOS (Per adnnt) ... UMBRELLA EXCESSLABA B �OCCUR EACH OCCURRENCE $ ICLAIMS-MADE AGGREGATE $ IDED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ,EACH ACCIDENT N E L FR...... ANY PROPRIETOR/PARTNER/EXECUTIVE $ OFFICER/MEMBER EXCLUDED? N/A TATU- OTH- (Mandatory in NH) Y/"""""' E,L.DISEASE-EA EMPLOYEE $ If yes,describe under ' DESCRIPTION OF OPERATIONS below _ E .DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Certificate holder is included as an additional insured as required by written contract. C'E'RTIFICATE HOLDER CANCELLATION EI Segundo Police Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 348 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S78290/M78283 LMK COMMERCIAL GENERAL LIABILITY EPA-1746 (10/2015) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - AUTOMATIC STATU'S WHEN REQUIRED IN CONTRACT OR AGREEMENT (OTHER THAN CONSTRUCTION) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to C. With respect to the insurance afforded to these include as an additional insured any person or additional insureds, the following additional organization when you and such person or exclusions apply: organization have agreed in writing in a contract, This insurance does not apply to: agreement, or permit, that such person or organization be added as an additional insured on 1. 'Bodily injury", "property damage" or "personal your policy. Such person or organization is an and advertising injury" arising out of the additional insured only with respect to liability for rendering of, or the failure to render, any "bodily injury", "property damage" or"personal and professional architectural, engineering or advertising injury"caused, in whole or in part, by: surveying services, including: 1. Your acts or omissions; or a. The preparing, approving, or failing to 2. The acts or omissions of those acting on your prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, behalf; change orders or drawings and in the performance of your ongoing operations for specifications; or the additional insured or in connection with your b. Supervisory, inspection, architectural or premises rented to you. engineering activities. However, the insurance afforded to such This exclusion applies even if the claims additional insured: against any insured allege negligence or other 1. Only applies to the extent permitted by law; wrongdoing in the supervision, hiring, 2. Will not be broader than that which you are employment, training or monitoring of others required by the contract or agreement to by that insured, if the 'occurrence" which provide for such additional insured; and caused the "bodily injury" or "property damage", or the offense which caused the 3. Only applies to 'occurrences" or coverages not "personal and advertising injury", involved the otherwise excluded under this policy. rendering of or the failure to render any B. Status as an additional insured for the person or professional architectural, engineering or organization to which this endorsement applies: surveying services. 1. Commences during the policy period and 2. 'Bodily injury" or "property damage" occurring after such written contract, written agreement after: or written permit has been executed; and a. All work, including materials, parts or 2. Ends when: equipment furnished in connection with a. Your ongoing operations for that additional such work, on the project (other than insured are completed; or service, maintenance or repairs) to be performed by or on behalf of the additional b. The lease of premises expires, or insured(s) at the location of the covered c. This policy is cancelled or otherwise operations has been completed; or terminates, b. That portion of"your work" out of which the whichever occurs first. injury or damage arises has been put to its intended use by any person or organization. EPA-1746 (10/2015) Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 2 with its permission. D. With respect to the insurance afforded to these additional insureds, the following is added to Section III—Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement you have entered into with the additional insured; or 2. Available under the applicable Limits of Insurance shown in the Declarations, whichever is less. This endorsement will not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 Includes copyrighted material of Insurance Services Office, Inc., EPA-1746(10/2015) with its permission. 11,4PINX.90i 246Jf 1,C)MIKiii 61LIVID,Sir, 4 AWMERCURY AUTIOAAWWX POLWY UCCLAWINXIS 90!0 �10 ill wi 11"'k�11 e� h 1:11 W P:'�I'd Ni IMPORTANT COVERAGE EXCLUSION pownfirmw 4OPWAULt KNAUCOIVE'RMAS ISM10104BUT WIT LAUIP0 W.UAWIWWV wow$0:'� IU 11 R"W'.IT i 1:�u,��911110 0�fiq u4qq IM V01,4 polfj('y 11111 �Iqdv�w h4ulilt'Q riOW 11,0VI"1 I'VWIN,lt I00 fl �11-lv U:,I"<.v vi�Ifir!!,Pb'j:jlq I MCA lrtl n,';IMJEIZ m,rpl,aaa�+,h,I'r Ii I,III, or"'I'.1,,0 -M,M"', "r 1,1 ihn Ir ,•u",,Yi mio twit Aeie MlA H 11flifl,,,: cr'( 4"A ii y"a trpMo UMMOVA V;01 V Q4 A 04ve Nrx.vIrl gi:009A PlAiA pllv'.'CXN NISSAfid 11 11,11:: n i:",woIoj WA'xQkm kv 'q:X1 41!'j 7 l,�I°+070' Co'IaPM'�r JIM, iiiIII-M, j rAAA'af,*:A"MINAH a`I ANO W"ARMAII htlif"I Ilil"I"i"'. Z I A YM,MWORS HNAUCk ALU Wr AVC 01)[Nl AIIN NIM ct, M" COVM'i i t fW WN I L AA t r V MMIUMS N(N-PACMAV I UWPIALUT l: C 14�": I! PIA� 1 110 E„I uur mk'� jq"Al, 104,1 AVID N'�JIQAIMT ring 11i MOR Aft. xIfAftb i4mm Imaz miuRwo Baum,^miuwct irna MIMI VAAWAIA11.1 oNty"o"w i ii mw WMAMIr 'Ari WAUMNY L"DeAk IXNN�:* pMAF 14 0ANI rAr UMILAIN �y 114 0 1 1 KPAW OR RMACPMENT CIAMPI vw I I I: I Kii I pff i � �l� nm Pou 40 V'11.E 04" 1 Al Iiii K�t�ff PfA IC V pii"A r"1% Por U 047,2,q S IIJ 45,91 fu A4.ro'by pip%A RMFOR O'ANT ffif`41AMA TON vY' 'Ili", dv- Mlisid !I ::': �v I i 4v; !IV mii':I!h lo s h":I, o:�'I: 0 A � I'li ;,:� 111 ' I i� 1:1 i� � l o' I:,; I I e"1 Iv i� V'I 1v' nO "obil:11 1 11; MCA R Cii 4:24SI V I NTGN A V E-N A- CULVER CETY, CA.002,32 10 176 INSURED COPY CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. affirm under penalty of perjury under the laws of California one of the following declarations: (_) I have and will maintain a certificate of consent of self-insure for workers'compensation, issued by the Director of Industrial Relations as provided for by Labor Code§3700 for the performance of the work set forth the agreement with the City of EI Segundo. Policy No. (_)I have and will maintain workers'compensation insurance as required by Labor Code§3700 for the performance of the work for which the agreement with the City of EI Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone# ) I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject o he workers' compensation provisions of Labor Code § 3700 1 must immediately comply with t. e prov' t the agreement will automatically become void. g� Signature of Applicant ��rutl� ,.��W Date 10/06/17 Agreement for: GYM MECHANIC .. A " Dated: Reviewed by: 1